​The following case example may help illustrate some of the complex and important issues identified regarding the use of the new minimum data set (MDS) 3.0 assessment tool, particularly around the psychosocial sections.

Mr. S, age 80, was admitted as a Medicare skilled nursing facility (SNF) resident after hip surgery because of a fall at his group home. Prior to his SNF admission, he lived in an adult home—he never managed to maintain an apartment as he went from job to job.

His rehabilitation therapy progress was good, and yet his discharge was determined not to be feasible because his group home would not accept him due to his inability to manage the stairs independently. His nursing home social worker and community case manager were unable to find alternative housing. After a 15-day SNF stay, he was transferred from the SNF directly to the nursing facility.

His OBRA annual assessment was completed on day 14. In the Mood Section of the MDS, Mr. S accurately indicates that he is not experiencing difficulty with eating, fatigue, sleep, concentration, or interest in extra-curricular activities. He scored a total severity of 5 on the PHQ 9 in contrast with the team’s assessment identifying depression. He expresses that he feels bad about himself and perseverates on thoughts that his medical condition is “evidence that God is punishing him” and his feelings of hopelessness.

He was raised in foster care and has two siblings—one is deceased, and the other has Alzheimer’s disease and is in a facility. Extended family is caring toward him but overwhelmed by caring for the family member with dementia. He indicates in Section Q that he wants to return to the group home. He has a long history of psychiatric illness and has a case manager as his main contact. While he is able to walk around the facility independently, he becomes frustrated due to expressive aphasia, and his Brief Interview for Mental Status (BIMS) score was 14, which shows strong cognitive abilities. The nursing home team is addressing his depression through psychotropic medications, including visits by a psychologist, a social worker, and pastor.

In the case example, Mr. S is being interviewed for his 14-day OBRA admissions assessment. He has a history within the facility of becoming frustrated when attempting to communicate his needs due to expressive aphasia. Facility staff are now attempting to complete the BIMS, PHQ 9, and preference interviews with Mr. S for at least the third time in the past 30 days. It is highly likely that he will experience feelings of anger and frustration when being interviewed and further compromise his overall well-being. The validity of the interview may also be decreased as the result of Mr. S responding negatively to the interviewer.

Social Workers and nurses indicated that the repeated interviews, especially for BIMS and PHQ 9, required for SNF and significant change assessments, result in residents refusing to answer the questions or elicit feelings of frustration that compromise the data being captured.

In addition, the staff assessment has to be completed when a resident refuses to answer resulting in additional time spent on paperwork instead of providing clinical support to residents. [In this case, the self-report and staff report are likely to differ since he presents differently to clinical staff compared with his self-report.]

Mr. S' case exemplifies many important care planning and CAA issues. First, the interdisciplinary care planning needs generated by his problems require clinical skills since his behavior is not consistent with his PHQ 9 score. Further, it is clear that his needs require the full complement of interdisciplinary staff, yet staff may be stretched by new MDS 3.0 documentation requirements or by lack of adequately trained mental health staff to assist Mr. S.

The social worker is a key team member to bring the care plan team together to address his needs and yet her/his priority is split between the SNF and the nursing facility (NF), with the NF often being the priority. It is estimated that it would take Mr. S’ social worker approximately three hours to complete the three CAAs, document depression needs in the medical record, and to coordinate with Mr. S’ case manager and the local contact agency regarding his desire to return to the community when it is unlikely that resources exist to support him.